Assessing the Primary Care Practice to Enhance Integration

1. Assessing the Primary Care Practice to Enhance Integration  May 16, 2012 Rebecca Morin, Maine Primary Care Association & Guests from Harrington Family Health Center

2. Today’s Objective Illustrate ways to use self-administered assessment tools to identify areas to advance integrated care, including the use of cross-functional teams and care coordination. 

3. Maine Primary Care Association (MPCA) • MPCA works with Maine’s Federally Qualified Health Centers (FQHCs), also known as Community Health Centers (CHCs) • They are: • Community-run non-profit primary care practices • In areas designated to be Medically Underserved Areas or serving a Medically Underserved Population (HRSA) • Seek to improve quality and access to care for all members of their communities

4. 18 Members-80% have co-located Behavioral Health/Substance Abuse Treatment Services-Screening for depression is most common -Nationally, 90% of FQHCs routinely screen for depression and 65% for substance abuse.

5. Support to Adopt/Enhance/Sustain BHI

6. The Players in FQHC Integration Specialty MH MA Psychiatry PATIENT RN PCP BH/MHC

7. Our Approach • Integration Concepts/Framework (5 Levels) • Improvement Roadmap (BHI SSA) • Improvement Strategies • Staffing ratio • Types of referrals • Communication • Documentation • Space • Support to Adopt/Enhance/Sustain Integration

8. 5 Levels of Collaboration Guiding the Work

9. The BHI Site Self Assessment (SSA) Adapted from the PCRS – Developed by the Robert Wood Johnson Foundation Diabetes Initiative, www.diabetesintiative.org; also adapted from the ACIC survey developed by the MacColl Institute for Healthcare Innovation, Group Health Cooperative. ADAPTED FROM MeHAF. Using the 1-10 scale in each row, circle (or mark in a color or bold, if completing electronically) one numeric rating for each of the 18 characteristics. If you are unsure or do not know, please give your best guess, and indicate to the side any comments or feedback you would like to give regarding that item. NOTE: There are no right or wrong answers.

10. BHI SSA Continued Practice/Organization 9 Characteristics with descriptions across the 5 levels 1. Organizational leadership….. 2. Patient care team… 3. Provider engagement….. 4. Continuity of care…. 5. Coordination of referrals/specialists…. 6. Data systems/ patient records… 7. Patient/Family input…. 8. Education/Training…. 9. Funding & resources…. Integrated Services & Patient/ Family-Centeredness 9 Characteristics with descriptions across the 5 levels 1. Co-location….. 2. Emotional/behavioral health needs 3. Treatment plans…. 4. Patient care informed by best practice…. 5. Patient/Family involvement…. 6. Communication with patients….. 7. Follow up…. 8. Social support…. 9. Linking to community resources…

11. Feedback Loop

12. Feedback Report Example Characteristic 8: Physician, team and staff education and training for integrated care ….. . . is provided for some (e.g. pilot) team members using established and standardized materials, protocols or curricula; includes behavioral change methods such as modeling and practice for role changes; training monitored for staff participation (self score of 2 out of 10). Has your CHC…… • Located and connected PCPs with training in • Short-term interventions • Problem-focused Treatment • Motivational Interviewing • SBIRT • PTSD & Trauma Interventions • Developed and implemented a strategy for sharing models & methods learned to enhance internal expertise? • If a provider participates in a training – are they given the opportunity/time to act as an ambassador & share this information across the practice? • Researched and identified professional development opportunities for integrated care? • MPCA offers the U Mass Primary Care Behavioral Health Certificate course each Fall • Virtual offerings including webinars, additional research request etc. • Set aside short periods of time for cross disciplinary participation in education and training? • Archived webinars with facilitated discussion • Case studies during lunch breaks one time per month

13. Works Cited for Feedback Report • Blount, Alexander. “Integrated Primary Care: Organizing the Evidence”, Families, Systems & Health: 21, 121-134, 2003 found at http://www.apa.org/journals/fsh.html • Bertakis, Klea, and Azari, R. “Patient-Centered Care is Associated with Decreased Health Care Utilization” Journal of the American Board of Family Medicine (May-June 2011) Vol. 24 No. 3 found at http://www.jabfm.org/content/24/3/229.full?sid=53483dda-1bd4-4e14-be93-c9189de2ec8a • Lardiere, Michael, Jones, E., Perez, M., “2010 Assessment of Behavioral Health Services Provided in Federally Qualified Health Centers” (January 2011), National Association of Community Health Centers found at http://www.nachc.com/client/NACHC%202010%20Assessment%20of%20Behavioral%20Health%20Services%20in%20FQHCs_1_14_11_FINAL.pdf • Miller, B., Kessler, R., Peek C.J., Kallenberg, G., “Establishing the Research Agenda for Collaborative Care” found at http://www.ahrq.gov/research/collaborativecare/ *content specific to BHI SSA feedback found in Practice and Performance Characteristics summaries. • “Paying for the Medical Home – Part 2: Social, Behavioral, and Environmental Factors in Payment Models” from the Safety Net Medical Home Initiative found at http://pdfsbox.com/pdf/safety-net-issue-2.html

14. PCMH (+BHI) Transformation Guided by the 8 Change Concepts of the Safety Net Medical Home Initiative (all 8 align with the 10 Core Expectations of Maine’s Patient Centered Medical Home Pilot.) Continuous and Team-Based Healing Relationships Patient-Centered Interactions Engaged Leadership Enhanced Access Care Coordination Organized, Evidence-Based Care The NCQA 2011 PCMH Standards is our chosen quality improvement strategy PCMH Standard 1: Enhance Access & Continuity PCMH Standard 2: ID & Manage Patient Populations (Element C, Factor 6) PCMH Standard 3: Plan & Manage Care (Element A, Factor 3)

15. Leverage to Achieve Integrated Care Patient Centered Medical Home (PCMH) Accountable Care Organization (ACO) Depression, Diabetes and CVD Collaboratives Tobacco Assessment & Cessation Support

16. Bill Wypyski, CEOConnie VanDam, Mental Health Care Coordinator / Tobacco Cessation Counselor Chris Skehan, QI/Risk Manager

17. HFHC -Who We Are Mission: Create a healthier community by engaging each patient in making health care decisions that reflect the highest standards of care in conjunction with the needs and desires of the patient and his/her family, and by making this care affordable based on patient’s ability to pay. • Services: • ~Complete Family Medical Care for All Ages which also includes: • -Laboratory Services • -Prescription Assistance • -Tobacco Cessation • -Nutrition Counseling • -Maine Breast and -Cervical Program • -Sports and DOT Physicals • ~Mental Health and Substance Abuse Counseling • ~Dental Services • ~Podiatry Service Area : Columbia, Columbia Falls, Addison, Milbridge, Steuben, Harrington and Cherryfield.

18. Our Journey Towards Integration • Self-Assessment • Education • Breaking Down Provider Barriers and Bias • Pilot Program-Placing a Mental Health Clinician ½ • day/week in primary care wing • Emphasize already established tobacco cessation • program • Hire new clinicians with integrated care model in mind.

19. Harrington BHI SSA Component I: Integrated Services & Patient/Family Centeredness Medical Care Manager + MH Care Coordinator Pt/Fmly Centered Solutions =

20. Harrington BHI SSA Component II: Practice/ Organization

21. Improvement Strategies at the Practice Level • BH/MH to Medical Staffing Ratio: 4(includes 1 Tobacco Specialist) to 6 • Types of referrals to BH/MH • Tobacco Cessation • Grief Counseling • ADHD • Substance Abuse • Depression • Trauma (Immediate & Long Term) • Anxiety • Situational Stress • Child Behavioral Issues • Couple/Family Issues • Communication • BH/MH have access to Medical Record but Medical staff do not have access to BH/MH Records • Referrals: EMR using secure email to MH Coordinator, warm hand-offs, pt self-referrals (phone or walk-ins), referral from non-HFHC providers. • Documentation • Space – BH/MH housed on 2nd floor  Future Plans for Brief Interventions

22. Behavioral / Mental Health Warm Hand-Offs for the Referral Process • Process: Warm hand- off from PC Clinician to MH Coordinator to begin and complete a Behavioral Health Referral either in house or to a Behavioral/Mental Health Specialist outside of health center i.e. psychiatric. Patient Need Identified via Medical Staff MH Coordinator Contacted Patient Need Assessed Pt in CRISIS? YES NO Pt seen by MH Clinician and (if needed) Crisis services. MH Coordinator/Nursing staff attend to pt. Patient scheduled to be seen w/in 2-3 days

23. Tobacco Cessation Support &“Different Shades” of Warm Hand-Offs

24. Plan-Do-Study-Act (PDSA) Cycle • Define the problem: Need for data to support the theory and anecdotal evidence that patients referred for tobacco cessation counseling are more engaged in their plans to become tobacco free if the referral occurs as a “warm hand-off” versus a “dry” referral (referral initiated via EHR with no direct initial contact between counselor and patient.)

25. PDSA Continued The Change: Increase the # of referred patients who are engaged in their care, thereby increasing their likelihood to keep appointments for counseling, and potentially increasing their ability to “quit”. Plan What are we testing? On whom are we testing the change? What do you expect to happen? (Prediction): (Data) What data do we need to collect? Who will collect the data? When will the data be collected? Where will the data be collected? DO Study What was actually tested? What happened? Observations/Problems: Complete analysis of data, summarize what was learned, compare to prediction: Act What changes should we make before the next cycle?

26. PDSA Snapshot DO!

27. In Conclusion Warm hand-offs help reiterate medical home “team” concept (Patient, Provider, Counselor) Our data helped “make the case” for moving towards more integrated care We were able to identifying solutions to services (BH/Medical) being in different spaces

28. Thank YouQuestions & Answers Contact Information: Rebecca Morin – MPCA – rmorin@mepca.org Bill Wypyski – Harrington Family Health Center – bill.wypyski@harringtonfamilyhealth.org